American Cancer Society Updates Annual Guidelines for Early Cancer Detection CME/CE
News Author: Laurie Barclay, MD
CME Author: Hien T. Nghiem, MD
This activity is supported by funding from WebMD.
http://www.medscape.com/viewarticle/522758
Release Date: February 1, 2006
Feb. 1, 2006 — The American Cancer Society (ACS) has updated their annual guidelines for the early detection of cancer. The new recommendations are published in the January/February issue of CA: Cancer Journal Clinic.
"Each January, the ACS publishes a summary of its recommendations for early cancer detection, including guideline updates, emerging issues that are relevant to screening for cancer, and a summary of the most current data on cancer screening rates for US adults," write Robert A. Smith, PhD, from the Cancer Control Science Department of the ACS in Atlanta, Ga, and colleagues. "In 2005, there were no updates to ACS guidelines. In this issue of the journal, we summarize the guidelines, discuss recent evidence and policy changes that have implications for cancer screening, and provide an update of the most recent data pertaining to participation rates in cancer screening by age, sex, and insurance status from the Centers for Disease Control and Prevention (CDC)'s Behavioral Risk Factor Surveillance System."
The annual recommendations also offer guidance to the public about testing for early detection for select cancers where mass screening is not recommended. At this time, several guidelines reviews and technology updates are in progress, regarding the prevention and early detection of skin cancer, breast cancer screening in women at known or suspected inherited risk for breast cancer, and testing stool for colorectal cancer. In 2006, ACS will publish an update on the recommendations for postpolypectomy and postcolorectal cancer resection follow-up, which was reviewed in collaboration with the US Multisociety Task Force on Colorectal Cancer.
ACS guidelines for breast cancer screening, which were last updated in 2003, note that average-risk women should have clinical breast examination (CBE) and counseling to raise awareness of breast symptoms, beginning at age 20 years, and regular mammography beginning at age 40 years. From ages 20 to 39 years, women should undergo CBE every 3 years, and annually after age 40 years. The ACS no longer recommends that all women conduct regular breast self-examination (BSE), but women should be informed about the potential benefits, limitations, and harms associated with BSE.
"Women also should be informed about the scientific evidence demonstrating the value of detecting breast cancer before symptoms develop, and the importance of adhering to a schedule of regular mammograms," the authors write. "Benefits include a reduction in the risk of dying from breast cancer, less aggressive therapy, and a greater range of treatment options. Women also should be told about the limitations of mammography, specifically that mammography will not detect all breast cancers, and some breast cancers detected with mammography may still have poor prognosis."
The potential harms of mammographic screening include false positives, unnecessary biopsy, and possible anxiety. The decision to stop mammography screening should be individualized considering the potential benefits and risks of screening in the context of overall health status and anticipated longevity.
At present, data are insufficient to recommend a specific surveillance strategy for high-risk women, but these women may benefit from earlier initiation of screening, screening at shorter intervals, and screening with additional modalities, such as ultrasound or magnetic resonance imaging. Over time, digital mammography may offer an improvement over conventional imaging for some groups of women.
ACS recommends that cervical cancer screening should begin approximately 3 years after the onset of vaginal intercourse, but no later than age 21 years. Until age 30 years, annual screening is recommended with conventional cervical cytology smears or biennial screening with liquid-based cytology. Subsequently, screening with either method may decrease to every 2 to 3 years for women who have had 3 consecutive, technically satisfactory normal or negative cytology results.
Alternatively, after age 30 years, women with the same history of normal cytology results may undergo human papillomavirus (HPV) DNA testing with conventional or liquid-based cytology, accompanied by counseling and education about HPV and HPV testing. Positive test results for HPV does not indicate the presence of cancer.
Average risk women aged 70 years and older with an intact cervix may chose to stop cervical cancer screening if they have had no abnormal or positive cytology tests within the 10-year period before age 70 years, and if the 3 most recent consecutive examinations were technically satisfactory and normal. Women with a history of cervical cancer or in utero exposure to diethylstilbestrol (DES) should follow the same guidelines as average risk women before age 30 years, but they should continue with that protocol thereafter.
Immunocompromised women should follow US Public Health Service and Infectious Disease Society of America guidelines (testing twice during the first year after diagnosis and annually thereafter).
Options for colorectal screening may be chosen based on individual risk, personal preference, and access. Average-risk adults should begin screening at age 50 years with one of the following: annual fecal occult blood test (FOBT) or fecal immunochemical test (FIT); flexible sigmoidoscopy every 5 years; annual FOBT or FIT, plus flexible sigmoidoscopy every 5 years; double-contrast barium enema (DCBE) every 5 years; or colonoscopy every 10 years.
The ACS recommends more intensive surveillance for individuals at higher risk for colorectal cancer, including those with a history of adenomatous polyps; those with a personal history of curative-intent resection of colorectal cancer; those with a family history of either colorectal cancer or colorectal adenomas diagnosed in a first-degree relative before age 60 years; those with a history of inflammatory bowel disease of significant duration; or those with a family history or genetic testing indicating the presence of 1 of 2 hereditary syndromes, such as hereditary nonpolyposis colorectal cancer and familial adenomatous polyposis.
Women at average and increased risk for endometrial cancer should be informed about risks and symptoms at the onset of menopause, and they should be strongly encouraged immediately to report these symptoms to their clinicians. Women at very high risk for endometrial cancer due to known hereditary nonpolyposis colorectal cancer–associated genetic mutation carrier status; substantial likelihood of being a mutation carrier; or absence of genetic testing results in families with suspected autosomal dominant predisposition to colon cancer should consider beginning annual testing for early endometrial cancer detection at age 35 years. Evaluation of endometrial histology is still the gold standard for determining the status of the endometrium.
Evidence about the value of testing for early prostate cancer detection is still insufficient to recommend that average-risk men undergo regular screening. The ACS therefore emphasizes the importance of shared decision making about testing. Men at high risk, including men of sub-Saharan African descent and men with a first-degree relative diagnosed at a younger age should begin testing at age 40 to 45 years. Because the prostate-specific antigen (PSA) test is specific to prostate tissue and not prostate cancer specific, there is no absolute cutoff value that is applicable to all men.
No organization currently recommends testing for early lung cancer detection in asymptomatic individuals at risk for lung cancer. However, the growth in the use of spiral computed tomography to test for early lung cancer detection in former and current smokers has led the ACS to emphasize the importance of informed decisions for individuals at risk who seek testing. Testing should be done only in multidisciplinary centers with experience in testing, diagnosis, and follow-up. Current smokers should be advised that the greatest priority is to stop smoking.
The regular periodic checkup should include the performance or referral for conventional cancer screening tests and is also an opportunity for case-finding examinations of the thyroid, testicles, ovaries, lymph nodes, oral region, and skin. Self-examination and increased awareness about signs and symptoms of cancer can be discussed. Health counseling may cover smoking cessation, diet, physical activity, and shared decision making about cancer screening.
The guidelines also include surveillance data on the estimated proportion of US adults undergoing specific tests for early cancer detection based on ACS cancer screening guidelines. The independent Task Force on Community Preventive Services, with the support of the CDC, the National Cancer Institute, and experts from public and private sectors, is now conducting a systematic review of studies of selected population-based cancer screening interventions.
"Too many adults are not receiving regular screening, and thus there is a persistent, avoidable fraction of advanced cancer diagnosed each year that could have been detected at an earlier, more treatable stage, or potentially even prevented," the authors conclude. "Although public education and outreach to clinicians and the public contribute to increasing cancer screening, it should be increasingly evident that greater investment in systems that support cancer screening and follow up, as well as opportunities for informed and shared decision making, are needed."
CA: Cancer J Clin. 2006;56:11-25
Clinical Context
Since 2000, the ACS has published annual reports reviewing current guidelines for early cancer screening and emerging issues that are relevant to screening and providing data on cancer screening rates for US adults. In this issue, data regarding cancer screening rates are based on a 2004 survey provided by the CDC and Behavioral Risk Factor Surveillance System. To highlight the impact of health insurance as a determinant of access to cancer screening, health insurance status for individuals younger than 65 years of age was evaluated. Established guidelines reviewed included breast, colorectal, prostate, and cervical cancer screening. These guidelines not only play an integral role in a primary care setting but also provide guidance to the public regarding their own healthcare.
Study Highlights
• Breast Cancer Screening
o BSE is acceptable for women to choose not to do or to do irregularly; however, women should be told about the benefits and limitations of BSE. Prompt reporting of any new breast symptoms to a health professional should be emphasized.
o For women between 20 and 39 years old, CBE should be performed at least every 3 years as part of the periodic health examination. Asymptomatic women 40 years or older should continue to receive CBE, preferably annually.
o Annual mammography should begin at age 40 years.
o Despite sufficient data to recommend a specific surveillance strategy for high-risk women, women at significantly increased risk for breast cancer may benefit from earlier initiation of screening, screening at shorter intervals, and screening with additional modalities, such as ultrasound or magnetic resonance imaging.
o Digital mammography vs screen-film mammography may have advantages, such as electronic storage, teleradiology, and image manipulation, in a select group of women.
o In 2004, the proportion of women aged 40 years and older reporting a mammogram was 58% vs 51% of women having both a mammogram and CBE. Uninsured women aged 40 to 64 years of age were less likely to have a mammogram (33.2%) or both a mammogram and CBE (28.2%) vs women with insurance.
• Colorectal Cancer Screening
o Begin screening at age 50 years, with 1 of the following options: (1) annual FOBT home kit or FIT; (2) flexible sigmoidoscopy every 5 years; (3) annual FOBT and flexible sigmoidoscopy every 5 years; (4) DCBE every 5 years; (5) colonoscopy every 10 years.
o Recent reports have raised concerns about the quality of FOBT, indicating low sensitivities in detecting cancer and inappropriate follow-up of a positive FOBT. 1-sample FOBT with stool collection during a DRE is not recommended and has been discouraged for colorectal cancer screening.
o In 2004, among adults 50 years and older, the prevalence of having either FOBT or endoscopy was 52.1%.
o Uninsured nonelderly vs insured individuals were significantly less likely to have colorectal cancer screening. 42.2% of adults with insurance reported recent endoscopy vs 18.8% of adult without insurance.
• Prostate Cancer
o Digital rectal examination (DRE) and PSA should be offered annually, starting at age 50 years, for men who have a life expectancy of at least 10 more years.
o In 2004, the proportion of men aged 50 years and older who reported having had a PSA test was 54%, and the prevalence of men who reported having DRE was 50.5%. Men of similar age range who lacked healthcare coverage were about half as likely to have had a PSA and/or a DRE vs men who had healthcare coverage.
• Cervical Cancer
o Screening should begin approximately 3 years after a woman begins having vaginal intercourse, but no later than 21 years of age. Screening should be done every year with conventional Papanicolaou tests or every 2 years using liquid-based Papanicolaou tests.
o At or after age 30 years, women who have had 3 consecutive normal test results may get screened every 2 to 3 years with cervical cytology alone or every 3 years with a HPV DNA test plus cervical cytology. The exception to this is women with a history of cervical cancer or in utero exposure to DES.
o Women aged 70 years or older who have had 3 or more normal Papanicolaou tests and no abnormal Papanicolaou tests in the last 10 years and women who have had a total hysterectomy may choose to stop cervical cancer screening.
o In 2004, 85% of women aged 18 years and older with an intact uterus reported having a Papanicolaou test within the past 3 years. Prevalence was lowest in women 18 to 64 years who lacked health insurance (75.7%).
Pearls for Practice
• In 2005, there were no changes to the ACS guidelines; however, a new update is underway for women at increased risk for breast cancer. Women may benefit from earlier initiation of screening, screening at shorter intervals, and screening with additional modalities, such as ultrasound or magnetic resonance imaging.
• The lack of healthcare insurance coverage decreased the prevalence of cancer screening for breast, colorectal, prostate, and cervical
